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Patient Safety & Clinical Pharmacy Services Collaborative Rebecca Cheek Director of Pharmacy White House Clinics 606-287-7104.

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Presentation on theme: "Patient Safety & Clinical Pharmacy Services Collaborative Rebecca Cheek Director of Pharmacy White House Clinics 606-287-7104."— Presentation transcript:

1 Patient Safety & Clinical Pharmacy Services Collaborative Rebecca Cheek Director of Pharmacy White House Clinics

2 Questions to Run On How can you implement Clinical Pharmacy Services at your site? Do you have a method in place to track Adverse Drug Events (ADE’s) and potential Adverse Drug Events (pADE’s)?

3 PSPC  Similar to other HRSA sponsored collaboratives  All Teach, All Learn environment  Starting 3 rd year in October 2010  White House Clinic has been involved since the beginning-August 2008

4 Our Collaborative Team Clinical Pharmacy Service Providers at the Primary Health Care Home Becky Cheek, PharmD Pharmacy Director Collaborative Lead Sharon Davidson, PharmD Steven Wagers, PharmD Melissa Zook, M.D. Family Physician Medical Director Sandra Dionisio, M.D. Internist Other Providers at the Primary Health Care Home

5 PSPC Collaborative AIM  To Save and Enhance thousands of lives each year by: –Achieving optimal health care outcomes and –Eliminating Adverse Drug Events through –Increased Clinical Pharmacy Services for the patients we serve  The Goal of Collaborative Services is to: –Improve patient safety –Improve patient health outcomes –Integration of cost-effective clinical pharmacy services

6 Our PSPC Aim Statement White House Clinics will strive to provide clinical pharmacy services to high- risk patients in an effort to decrease adverse events while encouraging those patients to become active partners in the management of their health condition.

7 What are Clinical Pharmacy Services?  CPS are patient-centered services that promote the appropriate selection and utilization of medications through: 1.Medication access*  340b formulary  Recommending generic alternatives  Patient Assistance Programs 2.Patient counseling *  Rx pick-up (required by OBRA-90)  Phone calls 3.Medication Therapy Management (MTM)*  Poly-pharmacy management  Recommendations given to patient or provider  Changes to therapy after DUR/ADE

8 CPS Services cont. 4. Preventive Care Programs  BMI or blood pressure  Immunizations  Drug Information Services to Patients 5. Drug Information Services to Patients*  Drug information leaflets  Disease state pamphlets 6.Medication Reconciliation Services  Having 1 accurate medication list

9 CPS services cont. 7. Provider Education*  Pharmacist provides evidence based drug information to provider 8.Retrospective Drug Utilization Review*  Review patients on certain meds or with certain disease states to assess quality and safety 9.Disease State Management*  Medications managed to obtain health outcomes and improve safety  Labs ordered and evaluated

10 CPS services cont 10.Prospective chart review and provider consultation*  Review chart before visit and make recommendations to provider team *Clinical pharmacy services that we provide at WHC

11 Why Are We Doing This Work?  Increase in multiple chronic conditions  Institute of Medicine Report: ADEs are leading cause of death and injury  Every $ spent on a RX = a $ spent on an ADE  Aging population/chronic disease – leading to high prevalence of poly-pharmacy  Lack of integration of clinical pharmacy services  Alignment with HRSA Core Measures

12 Key Benefits  It’s the Right Thing to Do for the Patients We Serve –Safer –Increased and Better Pharmacy Services –Improved Health Outcomes  Reduces/Manages Risk – and Risk is Increasing  Builds on and Takes Prior Knowledge Base and Experience to a New Level  Takes HRSA Collaborative Experiences to the Next Power

13 Key Benefits  Integrates Services to Maximize Community Health  Reduces Inappropriate Use of Poly-pharmacy – Better Medication Management  Helps Create New Partnerships & Synergies Across Provider Organizations  Exposure to Cutting Edge People and Methods on Quality Improvement, Leadership & Change Management  Opportunity to be a Part of a Major National Movement in a Rewarding All Teach, All Learn Environment

14 Examples of Disease States in Collaborative  Diabetes-HgA1C  Hypertension-blood pressure  Hyperlipidemia-LDL, triglycerides  Asthma-peak flow, ACT test, controller meds  Anticoagulation-INR in range  HIV




18 PSPC Outcomes: Improvements in Health Status  49% improved from health status “out of control” to “under control”  Across a range of chronic diseases, using standardized measures — such as A1C levels, blood pressure, LDL, INR ranges, depression scores, and viral load Average team improvement through July 2010

19 What did we need to do for the collaborative?  We needed to choose a Population of Focus (POF)  We needed to track ADE’s and pADE’s to improve safety

20 20 833,936 pat/year 16,284 pat/year pat/yr Total Population of Care that could benefit from CPS PSPC Population of Focus Total Population of Focus (Anticoagulant Treatment) 2% of Patients Can Benefit from CPS on One of the ISMP High-Alert Medications Total Patient Population

21 White House Clinics Improvement Story  Population of Focus – Patients receiving Coumadin® (Warfarin) therapy referred to the Coumadin Clinic for anticoagulation management  Baseline data unavailable as no data tracking methods in place  After enrolling, developed plan to collect data-manual, EMR template, EMR reports


23 Population of Focus  Indications CVA – 6% Atrial Fibrillation – 61.4% Mitral Valve Replacement – 10.8% Deep Vein Thrombosis – 13.3% Pulmonary Embolism –8.4%  Patient Age  <50 = 11  50 – 65 = 24  65 – 74 = 22  75 – 84 = 20  85 – 94 = 3  Setting Ambulatory – 75 Home Health - 5

24 High Risk Qualities in POF Panel Medications per Patient – 7 to 8 Providers per Patient – 3 Largest Safety Issues – Bleeding, Thrombotic Event Largest Health Status Problems – Hypertension, Atrial Fibrillation, Diabetes

25 Anticoagulation Management Data  %INR values within range (goal ) –Usual medical care with physician: 29.6% –Pharmacist-run Anticoagulation Clinic: 64% Chiquette E, Amato MG, and Bussey HI. Comparison of an Anticoagulation Clinic with Usual Medical Care. Arch Itern Med. 1998; 158:

26 White House Clinics INR In Range >80%

27 Improving Safety and Eliminating Adverse Events Tracking ADEs & pADE  ADE – Adverse Drug Event –Events that result in harm or injury to the patient due to medication use Example – Bleeding as a result of Coumadin® (Warfarin) administration  pADE – Potential Adverse Drug Event –Potential harm that was identified and avoided with appropriate interventions before reaching the patient Example – Pharmacist catches an allergy to Penicillin and calls the physician to change Amoxicillin to Azithromycin prior to dispensing Example – A Pharmacist notices a duplication of drug therapy (Lisinopril & Ramipril) and intervenes to have one of the medications discontinued before the patient receives the medication

28 ADE’s & pADE’s  No tracking prior to starting collaborative  Through the collaborative many organizations have observed a significant amount of ADE’s and pADE’s due to a lack in tracking data  Clinical Pharmacy Services have allowed these same organizations to see a decline in them over time

29 How We Should Identify ADEs/pADEs Medication Reconciliation Patient ADE/pADE Pharmacy Nurse/CMA Physician ER/Hospital

30 How Do We Plan On Collecting Data on ADEs/pADEs  Information concerning ADE’s and pADE’s will be collected from all available venues –The Patient –The Pharmacy –Medication Reconciliation –Nurse/CMA –Physician –ER/Hospital Visit  The data will be evaluated by the provider then entered into an EMR note. This data is easily extracted from EMR for reporting.

31 pADE’s and ADE’s for White House Clinic POF  pADE’s-low or high INR ranges, drug interactions, interruptions in therapy  ADE’s-bleeding, thrombosis

32 Example of pADE/ADE  22 y.o female dx: hypercoagulable state, s/p DVT/PE x5 Patient referred by primary care physician after INR had been followed by cardiologist. She could no longer afford to have INR monitored at cardio office. INR at initial visit =1.2. After CPS, we were able to bring her INR in range in a month. She was also determine to conceive. We assisted her with a Patient Assistance Program to get Lovenox and educated her on its use during pregnancy. We also provided counseling and an option to receive Chantix to stop smoking. She has been able to achieve appropriate anticoagulation levels and is now 3 months pregnant. Hopefully, our service avoided potential adverse drug events and actual adverse drug events for the patient and her unborn child.

33 White House Clinic pADEs/ADEs

34 The Assessment Scale is divided into the following categories:  1.0 — Forming team  1.5 — Planning for the project has begun  2.0 — Activity, but no changes  2.5 — Changes tested, but no improvement  3.0 — Modest improvement  3.5 — Improvement  4.0 — Significant Improvement-White House Clinic  4.5 — Sustainable Improvement  5.0 — Outstanding sustainable results Institute for Healthcare Improvement Assessment Scale

35 IHI Assessment Scale

36 PSPC 1 Awards  Health Outcomes Management Award –Successfully gathered data and reported it  Life Saving Patient Safety Award –Established systems to identify and prevent ADE’s and have an example of a life threatening ADE that was resolved  PSPC Performance Award –Showed overall excellence during the collaborative

37 PSPC 2.0 Awards  Health Outcomes Management Award

38 How did we do it?  Better, more focused education for patients  Closer patient follow-up  Better data tracking methods  Quality improvement efforts such as Byeth and CHADS2 scores  Collaborative competition  Communicated data to our providers  Required continuing education in disease state

39 The Next Step…PSPC 3  Spread of anticoagulation management to other sites  Asthma-working with pediatrician  Diabetes-working with Physician Assistant

40 What do we need?  Time –Hard to balance with other duties of a pharmacist  Staff –Hiring a new pharmacist  Resources –Pharmacy Expansion Grant, provider status for billing services, other funding  Support of our providers

41 Contact Information  Rebecca Cheek, PharmD  Office of Pharmacy Affairs  Healthcare Communities

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